Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign

Impact of The Real Cost Media Campaign on Youth Smoking Initiation

INTRODUCTION

The purpose of this study was to assess the relationship between youth exposure to the U.S. Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in smoking initiation.

METHODS

From November 2013 to November 2016, a longitudinal study of youth was conducted with a baseline and 4 post-campaign follow-up surveys. The sample consisted of nonsmoking youths from 75 U.S. media markets (n=5,103) who completed a baseline and at least 1 follow-up survey. Exposure was measured by media market-level target rating points and self-reported ad exposure frequency. Smoking initiation was examined among youths who had never smoked at baseline and defined as first trial of a cigarette. Discrete-time survival models using logistic regression and controlling for confounding influences were estimated. Analyses were conducted in 2018.

RESULTS

The odds of reporting smoking initiation at follow-up was lower among youths in media markets with higher levels of campaign advertisements than among those with less. Both between-wave and cumulative target rating points were associated with decreased risk of smoking initiation (AOR=0.69 [p<0.01] and AOR=0.89 [p<0.05], respectively); for every 3,500 between-wave target rating points on air, there was an associated 30% reduction in the hazard of smoking initiation among youths. Results from self-reported recall of the campaign advertisements found similar dose-response effects. The campaign is associated with an estimated 380,000-587,000 youths aged 11-19 years being prevented from initiating smoking nationwide.

CONCLUSIONS

Sustained national tobacco public education campaigns like The Real Cost can change population-level smoking initiation among youths, preventing future generations from tobacco-related harms.

The Relationship Between Exogenous Exposure to "The Real Cost" Anti-Smoking Campaign and Campaign-Targeted Beliefs

Though previous evaluations of "The Real Cost" anti-smoking campaign demonstrate effects on anti-smoking beliefs and behaviors, results rely on self-reported recall as a measure of exposure and are thus open to reverse causation concerns. Exogenous measures of exposure, assessed independently of outcomes, support stronger causal inferences. In this study, we examined the relationship between Target Rating Points (TRPs) for specific ads available over four-week periods and anti-smoking beliefs in a national sample of adolescent nonsmokers and experimenters (n = 4,780). Results demonstrate positive relationships between TRPs for ads targeting two of four belief categories tested (Control and Chemical; p < .05) and targeted-belief endorsement. Furthermore, moderation models indicate that ad-specific TRPs affected targeted beliefs more than non-targeted beliefs for those Control- and Chemical-targeted ads (p < .01). Findings support a claim of campaign effects while reducing concerns about reverse causal direction and the influence of unmeasured confounders.

Reactions to electronic nicotine delivery system (ENDS) prevention messages: results from qualitative research used to inform FDA's first youth ENDS prevention campaign

Background

Youth e-cigarette use is a major public health concern. Large-scale tobacco prevention campaigns are a proven strategy to prevent tobacco use. There is a gap in understanding what types of e-cigarette prevention messages might be most effective. This study addresses this gap by reporting youth reactions to health messages aimed at preventing e-cigarette use.

Methods

In 2018, twenty-four focus groups, with 159 teens (12–17) at risk for or experimenting with e-cigarettes were conducted in four cities across the USA. During focus groups, youth responded to creative concepts dealing with (1) the addictive nature of e-cigarettes, (2) the fact that e-cigarettes come in flavours, which may encourage youth initiation, and nicotine which may lead to addiction, or (3) that youth who use e-cigarettes are more likely to use cigarettes. Youth also gave feedback to specific facts about harmful and potentially harmful chemicals in e-cigarettes. Transcripts were analysed using thematic analysis.

Results

Messages focusing on addiction alone did not resonate with participants. While youth found the idea that e-cigarettes may contain nicotine and can be addictive believable, with many describing personal experiences of addiction, they questioned how bad this really was, comparing addiction to e-cigarettes to things like being addicted to food. Participants wanted more information about negative consequences of vaping. Concepts paired with strong health effects messages resonated with participants.

Conclusion

These focus groups clarified which e-cigarette prevention messages might be most persuasive to teens. Youth in this study responded favourably to messages stating specific health consequences of e-cigarette use.

The Role of Emotions and Perceived Ad Effectiveness: Evidence From the Truth FinishIt Campaign

PURPOSE

Examine association between emotional valence and intensity prompted by anti-tobacco advertising messages and perceived ad effectiveness among youth/young adults.

DESIGN

Online forced-exposure survey data from a nationally weighted, cross-sectional sample of youth/young adults, collected periodically over a 4-year period.

SETTING

National.

PARTICIPANTS

Thirty-seven cross-sectional surveys conducted online from June 2015 to January 2018; total N = 9534. All participants, aged 15 to 21, were in the intervention; no control group.

INTERVENTION

Individuals participating in premarket testing of truth ads were forced exposed to one of 37 anti-tobacco ads.

MEASURES

Emotional response, emotional intensity, and perceived ad effectiveness. Emotional response has been previously studied and measured. Including the discrete measure of "concerned" in positive emotions is unique to our study. It patterned with the other positive emotions when each ad was examined by each emotion. Intensity as measured in this study through the 5-point scale ("how much does this ad make you feel") is unique in the anti-tobacco ad literature. Although several past studies ranked the degree of emotion elicited by ads, they have not incorporated the intensity of emotion as reported by the participant themselves. The scale was used to determine whether perceived ad effectiveness is similar to those used in previous studies.

ANALYSIS

Linear regressions were estimated to assess type of emotional sentiment and level of intensity in relation to perceived effectiveness of the message.

RESULTS

All 9534 participants were exposed; no control group. The βs indicate how strongly the emotion variable influences the study outcome of perceived ad effectiveness. Positive emotions (β = .76) were more highly associated with perceived ad effectiveness (β = .06). Higher intensity with positive emotional sentiment and high-intensity negative produced the highest scores for perceived ad effectiveness (β = .30).

CONCLUSION

Eliciting a positive, high-impact emotional response from viewers can help improve perceived effectiveness, and in turn, overall ad effectiveness.

The Attitudinal and Motivational Effects of Anti-waterpipe Messages

Objectives: Waterpipe smoking can lead to negative health outcomes. In this study, we examined responses to anti-waterpipe smoking public service announcements (PSAs). Methods: In a pilot study, current waterpipe smokers (N = 20) and susceptible waterpipe never smokers (N = 25) were randomized to view either 3 anti-waterpipe PSAs, created by the Truth campaign, or 3 control videos. Participants answered questions pertaining to message acceptance at 3 time-points and perceived risk and motivation to quit or avoid waterpipe at 4 time-points. Results: Participants were recruited from the community (N = 45; Mage = 22.4 years). Whereas waterpipe smokers and never smokers who viewed the PSAs significantly increased in acceptance of (p < .05) and positive attitudes towards (p < .05) the messages with increased viewing of the mes- sages, waterpipe never smokers did so at a significantly higher rate (p < .05). Waterpipe never smokers who viewed the PSAs had increased perceived severity and susceptibility of health harms of waterpipe compared to the control (ps < .05). We also found gender differences. Conclusions: The 3 tested PSAs from the Truth campaign show evidence of effectiveness against waterpipe use.

Adolescents' receptivity to E-cigarette harms messages delivered using text messaging

INTRODUCTION

E-cigarette use among adolescents has dramatically risen since 2011, yet little research has tested e-cigarette harms messages among adolescents. We conducted a pretest-posttest pilot study to examine adolescents' receptivity to e-cigarette health harms messages delivered using text messaging.

METHODS

N = 69 adolescents were enrolled in an 8-day pretest-posttest text messaging study. Participants completed a pretest survey on day one, were texted one of three e-cigarette health harms messages per day on days two through seven, and completed a posttest survey on day eight (88% retention). We assessed message ratings at posttest and knowledge, thoughts, and beliefs about e-cigarette harms at pretest and posttest.

RESULTS

Adolescents rated the three messages favorably, with both the chemical and brain messages scoring higher than the nicotine message on fear arousal and perceived message effectiveness. More than one-third of adolescents showed the messages to others and talked to others about the messages. At posttest, knowledge about the harms of e-cigarettes, thinking about the risks of e-cigarettes, and perceived risks of e-cigarettes were all significantly higher compared to pretest (p < .05). Participants largely adhered to the text messaging protocol and found the study highly acceptable.

CONCLUSIONS

This pilot study suggests that adolescents are receptive to e-cigarette health harms messages and that delivering such messages using text messaging is feasible and acceptable. Future research should systematically develop and test a broad set of e-cigarette health harms messages and examine their impact in a randomized controlled trial.

Preventing Smoking Progression in Young Adults: the Concept of Prevescalation

As adolescents cross the threshold to young adulthood, they encounter more opportunities to engage in or accelerate previously discouraged or prohibited behaviors. Young adults, therefore, are more apt to initiate cigarette smoking and, more importantly, to accelerate their use if they tried and experimented as an adolescent. Preventing the escalation and entrenchment of smoking in the young adult years is critically important to reducing tobacco's long-term health toll. However, traditional interventions for youth have focused on preventing smoking initiation, and interventions for adults have focused on smoking cessation; both have failed to address the needs of young adults. We introduce the concept of "prevescalation" to capture the need and opportunity to prevent the escalation of risk behaviors that typically occur during young adulthood, with a focus on the example of cigarette smoking. Prevescalation negates the notion that prevention has failed if tobacco experimentation occurs during adolescence and focuses on understanding and interrupting transitions between experimentation with tobacco products and established tobacco use that largely occur during young adulthood. However, since risk behaviors often co-occur in young people, the core concept of prevescalation may apply to other behaviors that co-occur and become harder to change in later adulthood. We present a new framework for conceptualizing, developing, and evaluating interventions that better fit the unique behavioral, psychosocial, and socio-environmental characteristics of the young adult years. We discuss the need to target this transitional phase, what we know about behavioral pathways and predictors of cigarette smoking, potential intervention considerations, and research challenges.

Communication Regulatory Science: Mapping a New Field

Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.

Adolescents' Neural Response to Tobacco Prevention Messages and Sharing Engagement

INTRODUCTION

Interpersonal communication can reinforce media effects on health behavior. Recent studies have shown that brain activity in the medial prefrontal cortex during message exposure can predict message-consistent behavior change. Key next steps include examining the relationship between neural responses to ads and measures of interpersonal message retransmission that can be collected at scale.

METHODS

Neuroimaging, self-report, and automated linguistic measures were utilized to investigate the relationships between neural responses to tobacco prevention messages, sharing engagement, and smoking-relevant belief changes. Thirty-seven adolescent nonsmokers viewed 12 ads from the U.S. Food and Drug Administration's "The Real Cost" campaign during a functional magnetic resonance imaging scan session (2015-2016). Data were analyzed between 2016 and 2017. The extent that participants talked in detail about the main message of the ads, or sharing engagement, was measured through transcripts of participants' subsequent verbal descriptions using automated linguistic coding. Beliefs about the consequences of smoking were measured before and after the main experiment using surveys.

RESULTS

Increased brain activation in self- and value-related subregions of the medial prefrontal cortex during message exposure was associated with subsequent sharing engagement when participants verbally talked about the ads. In addition, sharing engagement was significantly associated with changes in participants' beliefs about the social consequences of smoking.

CONCLUSIONS

Neural activity in self- and value-related subregions of the medial prefrontal cortex during exposure to "The Real Cost" campaign was associated with subsequent sharing engagement, which in turn was related to social belief change. These results provide new insights into the link between neurocognitive responses to ads, the content of interpersonal sharing, and downstream health-relevant outcomes.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

"The Real Cost": Reaching At-Risk Youth in a Fragmented Media Environment

In 2014, the U.S. Food and Drug Administration launched its first youth smoking prevention media campaign, "The Real Cost," with the goal of preventing cigarette smoking among at-risk youth aged 12-17 years in the U.S. This paper examines how the paid media strategy was developed, implemented, and refined between 2013 and 2016. Specifically, this paper discusses how research and best practices informed the media targeting strategy used to implement a multifaceted national campaign that successfully reached and influenced thousands of teens at risk for cigarette smoking. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Bringing "The Real Cost" to Life Through Breakthrough, Evidence-Based Advertising

Building on the success "The Real Cost" campaign has already achieved requires the constant development of new audience insights, novel ideas, and unconventional ways of bringing the campaign to life. This article provides a high-level overview of the campaign's approach to developing and testing breakthrough advertising that has proven effective in preventing smoking initiation among a skeptical, hard-to-reach, at-risk youth audience. This approach is informed by evidence-based communication best practices for youth behavior change campaigns; insights from published literature and subject matter experts with decades of experience in youth health marketing and tobacco prevention; and findings from formative research studies conducted as part of the campaign development process. The paper also explores two campaign advertisements to showcase the research-based creative development process in action. This article is a collaboration between federal government officials, campaign managers, ad agency creatives, and researchers, and thus provides a unique, multidisciplinary examination into the research and creative processes that go into creating a national health communication effort. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Finding Pete and Nikki: Defining the Target Audience for "The Real Cost" Campaign

Successfully reaching at-risk teens aged 12-17 years with smoking-prevention messages capable of changing their knowledge, attitudes, and beliefs about cigarette smoking requires a multifaceted approach to understand the target audience's unique demographic, environmental, behavioral, interpersonal, and intrapersonal characteristics. This paper explores the initial target audience segmentation and insights development approach used to create the underlying message strategy for "The Real Cost" youth smoking prevention media campaign-a public education effort responsible for preventing nearly 350,000 U.S. youth aged 11-18 years from initiating smoking from 2014 to 2016. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

A Secondary Audience's Reactions to "The Real Cost" Advertisements: Results From a Study of U.S. Young Adult Smokers and Susceptible Nonsmokers

INTRODUCTION

Exposure to "The Real Cost" campaign has prevented smoking initiation among its target audience (U.S. youth aged 12-17 years). This study examines reactions to "The Real Cost" advertisements among a potential secondary audience: U.S. young adults.

METHODS

An online convenience sample of young adult (ages 18-29 years) smokers (n=225) and susceptible nonsmokers (n=339) participated in a within-subjects experiment in 2017. Participants viewed three TV ads from "The Real Cost" campaign and reported their past exposure to, conversations about, and reactions to the ads. In 2017, analyses examined message-level and person-level predictors of perceived message effectiveness using multilevel modeling.

RESULTS

About half of smokers (47%) and susceptible nonsmokers (51%) had seen at least one of the three ads in the past 3 months. About one in four smokers (23%) and susceptible nonsmokers (24%) had at least one conversation about the ads in the past 3 months. Susceptible nonsmokers rated the ads higher on perceived message effectiveness than smokers (p<0.01), but lower on message relevance and negative affective reactions to the ads (both p<0.05). In both samples, ads that elicited higher negative affective reactions and message relevance, and lower message reactance (i.e., resistance) received higher perceived message effectiveness ratings (all p<0.05).

CONCLUSIONS

"The Real Cost" ads have reached and generated conversations among a convenience sample of young adult smokers and susceptible nonsmokers. Increasing the perceived relevance and emotional reactions of campaigns may increase their impact. Future studies should examine reactions to "The Real Cost" campaign and effects on smoking behavior using nationally representative samples of young adults.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Fear and Humor Appeals in "The Real Cost" Campaign: Evidence of Potential Effectiveness in Message Pretesting

INTRODUCTION

In tobacco prevention campaigns, fear-appeal messages are widely used and generally shown to be effective, whereas the utility of humor appeals is less clear. This study compares the potential effectiveness of fear and humor ads developed for "The Real Cost" campaign.

METHODS

Adolescents (N=1,315) aged 13-17 years who were either experimenting with smoking or susceptible to smoking initiation were randomized to view either a single ad (of three fear and two humor ads in total) or nothing (control condition). Those in the ad viewing condition completed measures on fear, amusement, and perceived ad effectiveness. All participants completed measures on smoking attitudes and risk perceptions. Data were collected in 2014 and 2015. Analysis was performed in 2016.

RESULTS

Compared with control, both fear and humor ads produced greater risk perceptions (p<0.001). Fear ads also produced more negative smoking attitudes (p=0.001); humor ads had a similar effect on attitudes that approached significance (p=0.07). Fear ads scored higher on perceived ad effectiveness and fear, and lower on amusement than humor ads (p<0.001). In regression models, fear was a stronger predictor of perceived ad effectiveness, smoking attitudes, and risk perceptions than amusement for fear ads, whereas amusement was a stronger predictor of these outcomes than fear for humor ads.

CONCLUSIONS

Both fear and humor appeals have potential to be effective in "The Real Cost" campaign. Concurrent employment of these message strategies should help to diversify messaging and consistently recapture the target audience's attention.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Stakeholder Engagement in Developing an Electronic Clinical Support Tool for Tobacco Prevention in Adolescent Primary Care

Following guideline recommendations to promote tobacco prevention in adolescent primary care, we developed a patient-facing clinical support tool. The electronic tool screens patients for use and susceptibility to conventional and alternative tobacco products, and promotes patient–provider communication. The purpose of this paper is to describe the iterative stakeholder engagement process used in the development of the tool. During the pre-testing phase, we consulted with scientists, methodologists, clinicians, and Citizen Scientists. Throughout the development phase, we engaged providers from three clinics in focus groups. Usability testing was conducted via in-depth, cognitive interviewing of adolescent patients. Citizen Scientists (n = 7) played a critical role in the final selection of educational content and interviewer training by participating in mock-up patient interviews. Cognitive interviews with patients (n = 16) ensured that systems were in place for the feasibility trial and assessed ease of navigation. Focus group participants (n = 24) offered recommendations for integrating the tool into clinical workflow and input on acceptability and appropriateness, and anticipated barriers and facilitators for adoption and feasibility. Engaging key stakeholders to discuss implementation outcomes throughout the implementation process can improve the quality, applicability, and relevance of the research, and enhance implementation success.

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES

The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign.

METHODS

In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message.

RESULTS

Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source.

CONCLUSIONS

Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.

Adolescents' Aided Recall of Targeted and Non-Targeted Tobacco Communication Campaigns in the United States

We examined whether advertisements from two national tobacco control campaigns targeting adolescents (i.e., The Real Cost, Fresh Empire) and one campaign targeting adults (i.e., Tips from Former Smokers) were reaching adolescents. Data came from a national sample of adolescents aged 13 to 17 years (n = 975) surveyed by phone from August 2016 to May 2017. We assessed recall and attitudes toward five specific advertisements and three campaign slogans and examined differences by sub-groups. Almost all (95%) adolescents recalled seeing at least one campaign advertisement. Aided recall of The Real Cost and Tips from Former Smokers slogans was high (65.5% and 71.6%, respectively), while aided recall of Fresh Empire slogan was lower (15.3%) (χ² p-value: p < 0.001); however, Black adolescents had higher odds of recalling the Fresh Empire ad (aOR: 2.28, 95% CI: 1.39, 3.73) and slogan (aOR: 2.64, 95% CI: 1.06, 6.54) compared to White adolescents. Increased exposure to the advertisements (i.e., recalling more advertisements) was significantly associated with higher odds of reporting negative feelings toward tobacco products in 4/5 models (aORs from 1.34 to 1.61). Large-scale national campaigns can have wide reach among both targeted and non-targeted audiences with added benefits for cumulative cross-campaign exposure to advertisements.

Message and Delivery Preferences for Online Tobacco Education among Adolescents and Young Adults

Use of cigarettes and noncigarette tobacco products (NCTPs) among adolescents and young adults remains high. Strategies to communicate the risks of cigarettes and NCTPs are needed. Online tobacco education is one such strategy; however, there is little guidance for message development. We conducted four focus groups (n = 39) with adolescent and young adult to identify message and delivery preferences for online tobacco education. Participants evaluated three existing tobacco education websites. Transcripts were coded for preferred tobacco education message content, delivery, and willingness to use online tobacco education. Participants preferred novel, concise facts, embedded links to credible sources, and an anti-industry tone for website messages. Participants expressed an aversion to message strategies that relied on scare tactics or attempted to simulate youth media trends (e.g., overuse of hashtags). To increase exposure, participants recommended using social media to drive engagement. Results serve as guidelines for what information adolescents and young adults desire, as well as how they want this information communicated with online tobacco education. Our findings - youth prefer new, fact-based information that is conveyed concisely, with sources, without authoritative tones, and delivered via social media - provides guidance for how to develop online tobacco education for this at-risk population.

Cost-Effectiveness Analysis of The Real Cost Campaign's Effect on Smoking Prevention

INTRODUCTION

A previous study found that the Food and Drug Administration's The Real Cost national tobacco education campaign was associated with preventing approximately 350,000 U.S. youth from initiating smoking between 2014 and 2016. This study translates the reduction in smoking initiation into monetary terms by examining the cost effectiveness of the campaign.

METHODS

The cost effectiveness of The Real Cost was assessed by measuring efficiency in two ways: (1) estimating the cost per quality-adjusted life year saved and (2) estimating the total monetary return on investment by comparing the cost savings associated with the campaign to campaign expenditures. Analyses were conducted in 2017.

RESULTS

The Real Cost averted an estimated 175,941 youth from becoming established smokers between 2014 and 2016. Campaign expenditures totaled $246,915,233. The cost per quality-adjusted life year saved of the campaign was $1,337. When considering the costs of smoking, the averted established smokers represent >$31 billion in cost savings ($1.3 billion when only external costs considered). The overall return on investment of the campaign was $128 in cost savings for every $1 spent ($4 for every $1 spent when only external costs considered). These conclusions were robust to sensitivity analyses surrounding the parameters.

CONCLUSIONS

Campaign expenditures were cost efficient. The cost savings resulting from The Real Cost represent a large reduction in the financial burden to individuals, their families, and society as a result of tobacco. Public health campaigns, like The Real Cost, that reduce tobacco-related morbidity and mortality for a generation of U.S. youth also provide substantial cost savings.

Patterns in first and daily cigarette initiation among youth and young adults from 2002 to 2015

This study’s objective was to describe long-term trends and patterns in first cigarette use (cigarette initiation) and daily cigarette use (daily initiation) among youth and young adults in the U.S. We used cross-sectional survey data from the National Survey on Drug Use and Health, 2002–2015, to estimate annual incidence of first cigarette use (N = 270,556) and first daily cigarette use (N = 373,464) for each year by age groups, race/ethnicity and gender, examining trends over time and the average annual change in initiation for each group. Several clear patterns emerged: 1) cigarette initiation and daily initiation significantly decreased over time among those aged 12–14 and 15–17 and these trends were consistent among nearly all racial/ethnic and gender subgroups; 2) among 18–21 year olds, cigarette initiation sharply increased through 2009, surpassing rates among 15–17 year olds, and sharply declined through 2015 while remaining higher than rates among the younger group, and this trend was consistent for almost all racial/ethnic subgroups; 3) daily initiation for those aged 18–21 significantly declined, and this was significant among most subgroups 4) there was no change in cigarette initiation and daily initiation for 22–25 year olds overall and most subgroups; 5) there was a significant increase in cigarette initiation for 22–25 year old Hispanics males and daily initiation for 22–25 year old males. This study provides a comprehensive look at trends in cigarette and daily initiation among U.S. youth and young adults. Despite notable declines in smoking initiation among youth and young adult populations over the last two decades, targeted prevention and policy efforts are needed for subgroups at higher risk, including young adults and Hispanic males.

Adolescent neural responses to antismoking messages, perceived effectiveness, and sharing intention

Health communication delivered via media channels can substantially influence adolescents' choices, and the effects of messages are amplified through interpersonal sharing. However, the underlying psychological and neurocognitive mechanisms that influence message effectiveness and likelihood of sharing are not well understood, especially among adolescents. Based on research in adults, we hypothesized and preregistered that message-induced neural activation in regions associated with self-reflection, social processing, and positive valuation would be related to greater perceived ad effectiveness and intentions to share messages. We focused on brain activity in meta-analytically defined regions associated with these three processes as 40 adolescent nonsmokers viewed advertisements from "The Real Cost" antismoking campaign. Perceived message effectiveness was positively associated with brain activity in the hypothesized social processing regions and marginally associated with brain activity in self-relevance regions, but not associated with brain activity in valuation regions. By contrast, intentions to share the messages were not associated with neural response in these 3 systems. In contrast to previous neuroimaging studies with adult subjects, our findings highlight the role of social cognition in adolescent processing of persuasive messages. We discuss the possibility that the mental processes responsive to effective and shareworthy messages may reflect developmental processes pertinent to media effects.

Perceived Message Effectiveness Measures in Tobacco Education Campaigns: A Systematic Review

Target audience ratings of the likely impact of persuasive messages, known as perceived message effectiveness (PME), are commonly used during message development and selection. PME is also used to examine receptivity of messages after they are fully developed or deployed. Despite this, we know little about the conceptual and methodological characteristics of extant PME measures used in the literature. We conducted a systematic review of tobacco education video, print, and audio campaign studies to examine conceptual and methodological characteristics of PME measures. One hundred twenty-six PME measures from 75 studies conducted in 21 countries with more than 61,000 participants were reviewed. Results indicated considerable variability in measures' focus on general perceptions of a message (i.e., message perceptions) versus perceptions of expected message effects (i.e., effects perceptions). Considerable variability was also found on underlying persuasive constructs, use of referents, and referencing of behavior in PME items and measures. We conclude with several recommendations for future research on PME measurement and validation.

Perceptions of Alternative Tobacco Products, Anti-tobacco Media, and Tobacco Regulation among Young Adults: A Qualitative Study

Objectives With increased alternative tobacco product (ATP) use and lagging public health action, we explored perceptions of ATPs, anti-tobacco messaging, and tobacco regulation among young adults. Methods Semi-structured interviews were conducted with 60 Georgia college students aged 18-25 using: (1) cigarettes, little cigars/cigarillos (LCCs), smokeless tobacco, or e-cigarettes ≥15 days of the past 30; or (2) hookah ≥10 of the past 30 days (due to lower frequency of use). Of 99 participants recruited, 80 consented, and 60 participated. Results Participants were on average 21.01 years old (SD = 2.07), 56.7% women, and 65.0% black; 56.7% reported current use of cigarettes, 43.3% LCCs, 26.7% smokeless tobacco, 45.0% e-cigarettes, and 41.7% hookah. Cigarettes were perceived as most harmful to health and most addictive. E-cigarettes and hookah were generally regarded as lowest risk. Many indicated that ATP risk information was limited or inaccessible and that most anti-tobacco campaigns were irrelevant to ATPs. Participants requested more research and dissemination of evidence regarding ATP risks and need for ATP regulation. Conclusions In light of low risk perceptions regarding ATPs among young adults, research, anti-tobacco campaigns, and regulation must address their known and potential risks.

The Role of Knowledge and Risk Beliefs in Adolescent E-Cigarette Use: A Pilot Study

The use of e-cigarettes and other vaping devices among adolescents is an urgent public health problem due to the concern about adolescent exposure to nicotine. This study examined: (1) adolescents’ knowledge and beliefs about e-cigarette risks; and (2) whether knowledge and risk beliefs were associated with e-cigarette use. N = 69 adolescents completed a cross-sectional survey about e-cigarette knowledge, attitudes (i.e., risk beliefs), and behavior (KAB). Nearly half (47%) of the sample reported ever using e-cigarettes. The majority of adolescents knew about many of the risks of e-cigarettes, with no differences between never- and ever-users. However, risk beliefs, such as worrying about health risks of using e-cigarettes, varied across groups. Compared to never-users, e-cigarette ever-users were significantly less likely to worry about e-cigarette health risks, less likely to think that e-cigarettes would cause them negative health consequences, and less likely to believe that e-cigarette use would lead to addiction. In a multivariable logistic regression, prior combustible cigarette use, mother’s education, and addiction risk beliefs about e-cigarettes emerged as significant predictors of adolescents’ e-cigarette use. This study reveals that while knowledge is not associated with adolescent e-cigarette use, risk beliefs do predict use.

Cigarette pack messages about toxic chemicals: a randomised clinical trial

Background

The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers’ cigarette packs.

Methods

Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking.

Results

In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05).

Discussion

Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges.

Trial registration number

NCT02785484.

Early Life Exposures and Adult Cancer Risk

Very little is known about the influence of early life exposures on adult cancer risk. The purpose of this narrative review was to summarize the epidemiologic evidence relating early life tobacco use, obesity, diet, and physical activity to adult cancer risk; describe relevant theoretical frameworks and methodological strategies for studying early life exposures; and discuss policies and research initiatives focused on early life. Our findings suggest that in utero exposures may indirectly influence cancer risk by modifying biological pathways associated with carcinogenesis; however, more research is needed to firmly establish these associations. Initiation of exposures during childhood and adolescence may impact cancer risk by increasing duration and lifetime exposure to carcinogens and/or by acting during critical developmental periods. To expand the evidence base, we encourage the use of life course frameworks, causal inference methods such as Mendelian randomization, and statistical approaches such as group-based trajectory modeling in future studies. Further, we emphasize the need for objective exposure biomarkers and valid surrogate endpoints to reduce misclassification. With the exception of tobacco use, there is insufficient evidence to support the development of new cancer prevention policies; however, we highlight existing policies that may reduce the burden of these modifiable risk factors in early life.

Fighting Fire With Fire: Using Industry Market Research to Identify Young Adults at Risk for Alternative Tobacco Product and Other Substance Use

Limited public health research has used psychographic profiling to segment young adults and examine their substance use behaviors. We aimed to conduct market research to identify young adult market segments at risk for alternative tobacco products (ATPs), alcohol, and marijuana use. Substance use; psychographics per the Values, Attitudes, and Lifestyle Scale (VALS); and other key variables were assessed at baseline in a longitudinal study of 3,418 students aged 18-25 from seven colleges/universities in the state of Georgia. Cluster analysis was conducted on VALS factors to identify distinct segments. Regression examined segments in relation to substance use risk. Past 30-day use prevalence for each substance was as follows: cigarettes, 13.3%; little cigars/cigarillos (LCCs), 11.2%; smokeless tobacco (SLT), 3.6%; e-cigarettes, 10.9%; hookah, 12.2%; alcohol, 63.1%; and marijuana, 19.0%. Five segments were identified, created, and named: Conventionals, Simple Lifes, Open Minds, Confident Novelty-seekers, and Stoic Individualists. Controlling for sociodemographics, Open Minds, Confident Novelty-seekers, and Stoic Individualists (vs. Conventionals [referent]) were more likely to smoke cigarettes. Confident Novelty-seekers were more likely to use LCCs. Simple Lifes were less likely to use SLT. Open Minds and Confident Novelty-seekers were more likely to use e-cigarettes. Open Minds were more likely and Simple Lifes were less likely to use hookah. Open Minds were more likely to use alcohol; Simple Lifes and Stoic Individualists were less likely to use alcohol. Open Minds were more likely to use marijuana. Market research is an effective strategy for identifying young adults at risk for using distinct ATPs and can inform targeted health campaigns and cessation interventions.

Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco

INTRODUCTION

Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

METHODS

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

RESULTS

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

CONCLUSIONS

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

Recall of "The Real Cost" Anti-Smoking Campaign Is Specifically Associated With Endorsement of Campaign-Targeted Beliefs

Though previous research suggests the FDA's "The Real Cost" anti-smoking campaign has reduced smoking initiation, the theorized pathway of effects (through targeted beliefs) has not been evaluated. This study assesses the relationship between recall of campaign television advertisements and ad-specific anti-smoking beliefs. Respondents in a nationally representative survey of nonsmoking youths age 13-17 (n = 4,831) reported exposure to four The Real Cost advertisements and a fake ad, smoking-relevant beliefs, and nonsmoking intentions. Analyses separately predicted each targeted belief from specific ad recall, adjusting for potential confounders and survey weights. Parallel analyses with non-targeted beliefs showed smaller effects, strengthening claims of campaign effects. Recall of four campaign ads (but not the fake ad) significantly predicted endorsement of the ad-targeted belief (Mean β = .13). Two-sided sign tests indicated stronger ad recall associations with the targeted belief relative to the non-targeted belief (p < .05). Logistic regression analyses indicated that respondents who endorsed campaign-targeted beliefs were more likely to have no intention to smoke (p < .01). This study is the first to demonstrate a relationship between recall of ads from The Real Cost campaign and the theorized pathway of effects (through targeted beliefs). These analyses also provide a methodological template for showing campaign effects despite limitations of available data.

Exposure and Engagement With Tobacco- and E-Cigarette-Related Social Media

PURPOSE

Little is known about the nature and extent of adolescents' exposure to tobacco- and e-cigarette-related communications on social media. In this study, we describe the prevalence and correlates of youth exposure and engagement with tobacco- and e-cigarette-related social media.

METHODS

Data are from the baseline survey of the Texas Adolescent Tobacco and Marketing Surveillance system, a cross-sectional sample of sixth, eighth, and 10th graders (n = 3907, N = 461,097). Weighted logistic regression models were used to examine associations between demographic characteristics, sensation seeking, tobacco use, and exposure and engagement with tobacco-related social media.

RESULTS

Overall, 52.5% of students reported exposure to tobacco-related social media in the past month, whereas < 6% reported engagement. Exposure and some forms of engagement were more common among high school students, girls, those with friends who use tobacco, and high sensation seekers (p < .05). The odds of exposure were significantly higher among students susceptible to combustible tobacco (adjusted odds ratio [AOR] = 1.71, p < .05), e-cigarettes (AOR = 2.10, p < .01), and both combustible tobacco and e-cigarettes (AOR = 2.24, p < .001). The odds of engaging with social media was higher among those who were susceptible to, had ever, or currently use both combustible tobacco and e-cigarettes (AOR = 2.10-3.46, p < .05).

CONCLUSIONS

About 1 in every 2 adolescents in Texas are exposed to tobacco-related social media. Adolescents who are susceptible to or use e-cigarettes and/or combustible tobacco are exposed to and engage with tobacco-related social media more than their peers. Social media appears to be an important venue when targeting vulnerable youth in prevention campaigns.

Effect of a National Tobacco Public Education Campaign on Youth’s Risk Perceptions and Beliefs About Smoking

Purpose:

To assess the relationship between youth’s exposure to the Food and Drug Administration’s national tobacco public education campaign, The Real Cost, and changes in campaign-targeted beliefs.

Design:

Longitudinal design with baseline survey and 2 postcampaign follow-up surveys.

Sample:

Youth from 75 US media markets (N = 1680) who completed all 3 surveys and had experimented with or were susceptible to future cigarette smoking.

Measures:

Exposure was measured by self-reported frequency of ad exposure and media market–level target rating points. Agreement with 30 self-reported tobacco-related beliefs was assessed in 3 categories: (1) beliefs specifically targeted by campaign messages (campaign-targeted belief), (2) beliefs not targeted by the campaign (nontargeted beliefs), and (3) beliefs corresponding to other media campaigns on air concurrent with The Real Cost (ambiguous beliefs).

Analysis:

Descriptive analyses of aggregate changes in beliefs and logistic regressions to examine the association between campaign exposure and beliefs.

Intervention:

The Real Cost.

Results:

Agreement with campaign-targeted beliefs increased from baseline to first and second follow-ups, with a mean relative increase of 10.4% and 11.5%, respectively. Nontargeted beliefs did not change substantially. Both measures of campaign exposure were positively associated with increased odds of agreeing with 5 of 8 campaign-targeted beliefs. Exposure was not significantly associated with 12 of 14 nontargeted tobacco-related beliefs.

Discussion:

A sustained national tobacco public education campaign can change population-level perceptions of tobacco-related harms among youth.

Measuring youth beliefs about the harms of e-cigarettes and smokeless tobacco compared to cigarettes

This study examined validity of direct and indirect measures of perceived harm of e-cigarettes and smokeless tobacco (SLT) compared to cigarettes. On direct measures, people compare one product to another, whereas on indirect measures, people rate each product separately and the researcher compares these ratings. Data from youth in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014) were analyzed (N=13,651 youth aged 12-17years). The study included direct measures of perceived harm of e-cigarettes and SLT compared to cigarettes, and indirect measures were created by comparing ratings of the products. Weighted multinomial logistic regressions tested criterion validity by assessing whether direct and indirect measures were associated with criterion variables, including use of e-cigarettes and SLT. Youth were more likely to rate e-cigarettes as less harmful than cigarettes on the indirect measure (67.3%) than the direct measure (50.2%). The same pattern held for ratings of SLT as less harmful than cigarettes (indirect: 29.7%; direct: 11.7%). Direct measures explained unique variance in product use criterion variables even after adjusting for indirect measures, as did indirect measures after adjusting for direct measures. However, the criterion variables were more often associated with the direct measures than the indirect measures. Results offer preliminary support for using both direct and indirect measures when assessing youth's perceived relative harm of various types of products. However, if researchers cannot include both direct and indirect measures in a study, associations with product use criterion variables support prioritizing direct measures.

Recruiting and retaining youth and young adults: challenges and opportunities in survey research for tobacco control

INTRODUCTION

Evaluation studies of population-based tobacco control interventions often rely on large-scale survey data from numerous respondents across many geographic areas to provide evidence of their effectiveness. Significant challenges for survey research have emerged with the evolving communications landscape, particularly for surveying hard-to-reach populations such as youth and young adults. This study combines the comprehensive coverage of an address-based sampling (ABS) frame with the timeliness of online data collection to develop a nationally representative longitudinal cohort of young people aged 15-21.

METHODS

We constructed an ABS frame, partially supplemented with auxiliary data, to recruit this hard-to-reach sample. Branded and tested mail-based recruitment materials were designed to bring respondents online for screening, consent and surveying. Once enrolled, respondents completed online surveys every 6 months via computer, tablet or smartphone. Numerous strategies were utilized to enhance retention and representativeness RESULTS: Results detail sample performance, representativeness and retention rates as well as device utilization trends for survey completion among youth and young adult respondents. Panel development efforts resulted in a large, nationally representative sample with high retention rates.

CONCLUSIONS

This study is among the first to employ this hybrid ABS-to-online methodology to recruit and retain youth and young adults in a probability-based online cohort panel. The approach is particularly valuable for conducting research among younger populations as it capitalizes on their increasing access to and comfort with digital communication. We discuss challenges and opportunities of panel recruitment and retention methods in an effort to provide valuable information for tobacco control researchers seeking to obtain representative, population-based samples of youth and young adults in the U.S. as well as across the globe.

Perceptions of the Food and Drug Administration as a Tobacco Regulator

OBJECTIVES

The U. S. Food and Drug Administration (FDA) now has regulatory authority over all tobacco products. Little is known about public awareness and perceptions of FDA in their new role as a tobacco regulator. This research utilizes focus groups to examine perceptions of FDA as a tobacco regulator so that FDA can better communicate with the public about this role.

METHODS

We conducted 6 focus groups in 2014 among a diverse sample of smokers and non-smokers. Participants were asked if they had heard of FDA, what they knew about FDA, if they associated FDA with tobacco, and their thoughts about this FDA role.

RESULTS

A total of 41 individuals participated. Although nearly all participants had heard of FDA, most were not aware of FDA's regulatory authority over tobacco products, did not associate the role of FDA with tobacco, and some drew comparisons between FDA's work in tobacco and their work regulating food and drugs.

CONCLUSION

Data suggest that although public awareness of FDA regulatory authority over tobacco is low, with proper public education, the public may find FDA to be a trustworthy source of tobacco regulation.

Impact of The Real Cost Campaign on Adolescents' Recall, Attitudes, and Risk Perceptions about Tobacco Use: A National Study

The Food and Drug Administration’s (FDA) The Real Cost campaign advertisements (ads) have targeted U.S. youth with messages designed to prevent and reduce tobacco use. This study examined exposure to The Real Cost campaign, including ad and slogan recall, and associations with attitudes and risk perceptions among U.S. adolescents. We analyzed data from a nationally representative sample of adolescents aged 13 to 17 years (n = 1125) surveyed by phone from October 2014 to June 2015. We assessed aided recall of and attitudes toward four campaign ads and the one slogan. Logistic regression models assessed whether aided recall of The Real Cost ads or slogan was associated with perceived likelihood of serious health consequences of cigarette smoking. Most (88%) adolescents reported seeing or hearing at least one of four ads for The Real Cost, and 54% recalled The Real Cost slogan. The majority of adolescents reported more negative attitudes toward tobacco products after seeing or hearing the ads. Recall of any The Real Cost ad was significantly associated with greater perceptions of serious health consequences of cigarette smoking (Adjusted Odd Ratios (AOR) = 5.58, 95% Confidence Interval (CI) = 1.20–25.90). The FDA’s The Real Cost campaign has achieved very high reach and is associated with more negative attitudes toward tobacco products and greater risk perceptions of cigarette smoking among U.S. adolescents.

Quitting smoking during substance use disorders treatment: Patient and treatment-related variables

Although individuals in substance use disorders (SUD) treatment continue to smoke at high rates, regulatory, policy and programming changes promoting tobacco cessation are being implemented and some patients quit successfully. We examined associations of smoking patterns, tobacco advertising receptivity, anti-tobacco message awareness, health risk perception, attitudes towards addressing smoking and availability of smoking cessation services with quitting smoking during SUD treatment. Surveys were completed by 1127 patients in 24 programs chosen randomly, stratified by program type (residential, methadone maintenance, outpatient), from among publicly funded, adult treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Among respondents who had been in SUD treatment for at least one month, there were 631 current smokers and 52 former smokers who reported quitting smoking during treatment for at least one month prior to survey completion; these respondents comprised our sample (N=683). Results showed that participants who reported health concerns as a reason for quitting were 1.27 times more likely to have quit during treatment (p=0.015) than those reporting health concerns affected quitting a little or not at all. Additionally, participants who reported that smoking cessation was part of their personal treatment plan during SUD treatment were 1.08 times more likely to have quit during treatment (p<0.001). Participants in methadone treatment were 49% less likely to report successfully quitting during treatment than those in outpatient treatment (95%CI: 0. 35-0.75, p<0.001). Leveraging health concerns about smoking and including smoking cessation in an individualized treatment plan may help increase smoking cessation during SUD treatment.

Youth Receptivity to FDA's The Real Cost Tobacco Prevention Campaign: Evidence From Message Pretesting

In February 2014, the Food and Drug Administration launched The Real Cost, a national youth tobacco prevention campaign. This article examines youth receptivity to potential campaign ads using data from 3 message pretesting studies featuring the same design and consistent instrumentation. A total of 3,258 adolescents ages 13-17 were randomized to either an ad-viewing condition or a no-exposure control condition. Perceived ad effectiveness, smoking-related beliefs, and attitudes were measured as outcome variables. The sample consisted of both experimental smokers (58%) and current nonsmokers at risk for cigarette initiation (42%). A total of 14 ads were tested across the three studies. Participants who viewed the ads generally considered them to be effective (with a mean perceived ad effectiveness score of 3.66 on a scale from 1 to 5). Compared to those in the control condition, participants in the ad-viewing condition reported stronger beliefs about the health risks of smoking (p < .001), a greater likelihood that smoking would lead to loss of control in life (p < .001), and more negative attitudes toward smoking (p < .001). Responses to campaign ads were largely consistent between experimenters and at-risk nonsmokers. Implications of the findings for the campaign are discussed.

Adolescent and Young Adult Perceptions of Hookah and Little Cigars/Cigarillos: Implications for Risk Messages

Use of hookah and little cigars/cigarillos (LCCs) is high among adolescents and young adults. Although these products have health effects similar to cigarettes, adolescents and young adults believe them to be safer. This study examined adolescent and young adult perceptions of hookah and LCCs to develop risk messages aimed at discouraging use among users and at-risk nonusers. Ten focus groups with 77 adolescents and young adults were conducted to explore their perceptions about the perceived risks and benefits of hookah and LCC use. Participants were users of other (non-cigarette) tobacco products (n = 47) and susceptible nonusers (n = 30). Transcripts were coded for emergent themes on participants' perceptions of hookah and LCCs. Participants did not perceive health effects associated with hookah and LCC use to be serious or likely to happen given their infrequency of use and perceptions that they are less harmful than cigarettes. Participants generally had positive associations with smoking hookah and LCCs for several reasons, including that they are used in social gatherings, come in various flavors, and can be used to perform smoke tricks. Because adolescents and young adults underestimate and discount the long-term risks associated with hookah and LCC use, effective messages may be those that focus on the acute/immediate health and cosmetic effects.

Understanding how perceptions of tobacco constituents and the FDA relate to effective and credible tobacco risk messaging: A national phone survey of U.S. adults, 2014-2015

BACKGROUND

The passage of the 2009 Family Smoking Prevention and Tobacco Control Act has necessitated the execution of timely, innovative, and policy-relevant tobacco control research to inform Food and Drug Administration (FDA) regulatory and messaging efforts. With recent dramatic changes to tobacco product availability and patterns of use, nationally representative data on tobacco-related perceptions and behaviors are vital, especially for vulnerable populations.

METHODS

The UNC Center for Regulatory Research on Tobacco Communication conducted a telephone survey with a national sample of adults ages 18 and older living in the United States (U.S.). The survey assessed regulatory relevant factors such as tobacco product use, tobacco constituent perceptions, and tobacco regulatory agency credibility. The study oversampled high smoking/low income areas as well as cell phone numbers to ensure adequate representation among smokers and young adults, respectively. Coverage extended to approximately 98 % of U.S. households.

RESULTS

The final dataset (N = 5,014) generated weighted estimates that were largely comparable to other national demographic and tobacco use estimates. Results revealed that over one quarter of U.S. adults, and over one third of smokers, reported having looked for information about tobacco constituents in cigarette smoke; however, the vast majority was unaware of what constituents might actually be present. Although only a minority of people reported trust in the federal government, two thirds felt that the FDA can effectively regulate tobacco products.

CONCLUSIONS

As the FDA continues their regulatory and messaging activities, they should expand both the breadth and availability of constituent-related information, targeting these efforts to reach all segments of the U.S. population, especially those disproportionately vulnerable to tobacco product use and its associated negative health outcomes.